Health Care Delivery System

1. Health Care Delivery System

2. Evolution of HCDS • Early 20th Century – Prepaid medical plans –lumber and mining camps Nursing care still focused in homes • 1920 – American hospitals offered “Baylor Plan” (later Blue Cross) – • 1935 – Social Security - benefits for elderly, child welfare, training of healthcare personnel • WWII – veteran healthcare benefits

3. 1960’s– Medicare and Medicaid health care services for elderly and indigent • Nursing Training Act (physician and nurse shortage) • Nurse Practitioners began • Focus moves to health maintenance • 1970’s – HMO Act – primary health care service for a predetermined fee • Amendments to SS allow nurse practitioners to be paid directly for service • Rural Health Clinic Service Act

4. 1980’s – Focus on Cost Control • “OBRA” – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) • DRG’s (Diagnosis Related Groups) • HMO’s increase • Technology proliferates • AIDS discovered 1980’s – Focus on Cost Control – OBRA – Omnibus Budget Reconciliation Act (peer review, quality, restraints, payment to midwives) HMO’s increase Technology proliferates AIDS discovered

5. 1990’s – Medicaid and welfare program reforms: welfare to work • SCHIP – Children’s health insurance program • UAP’s (unlicensed assistive personnel) • 2000’s – More telemedicine utilization

6. Levels of Health Care Primary – Health Promotion and Illness Prevention • Ideal level to enter the health care system • Teaching, lifestyle modification, referrals, immunization, promote safe environment

7. Secondary – Early detection, Diagnosis and Treatment • Screening, diagnosis • Acute Care • Surgery

8. Tertiary – Restorative and Rehabilitation actviities– return to optimal functioning • Education and retraining • Environmental modifications • Provision of direct care

9. Health Care Settings • Hospitals – General and specialized Proprietary Teaching and Research Public Voluntary

10. Health Care Settings • Ambulatory Services Outpatient departments Physician group practices HMO’s Nursing Care Centers Community Health Clinics Indian Health Service Ambulatory Care Facilities (urgent care centers)

11. Health Care Settings • Long Term Care Facilities Residential care Assisted Living Skilled Care • Public Health Agencies • Home Care Agencies • Adult Day Care • Wellness Centers • Hospice Care – hospital, nursing home, free-standing hospice, home

12. Health Care Team Guess the professional: Has completed a 120 hour course in basic life support skills and passed a national test. Provides care in an emergency

13. EMT • ??? Has a minimum 2 year preparation and performs diagnostic measures involving radiant energy

14. X-ray technician • ??? A nurse who has studied an additional 2-3 years in an approved school or anesthesiology

15. CRNA (Certified Registered Nurse Anesthetist) • ???Graduate of a 12-18 month program and passed a certifying exam - provides treatments for breathing

16. Respiratory Therapist • ???? Provides assistance for mobility and exercises – has completed a 2 year program

17. PTA – Physical Therapy Assistant • ??? Has completed 4-5 years of education plus an internship regarding nutritional problems and therapeutic diets

18. Dietician • ??? A graduate of a 4 year or more program who helps patients restore body function through specific tasks and skills related to activities they need to function in their daily lives

19. Occupational Therapist • ??? A professional who helps the patient solve problems with financial concerns, assist with obtaining services in the community after discharge and has completed a master’s degree.

20. Social Worker (MSW)

21. Financing • Public • Private • Third Party

22. Financing Health Care • Fee for service – physician paid by patient for each service provided • Capitation – set monthly fee charged by provider for each member of group for a specific set of services

23. Fee for Service - Terminology • Premium • Deductible • Co-Payment • Co-Insurance • Health Care Provider

24. Public Financing - Medicare • Part A – Hospital Insurance Provided free for those who have 40 or more quarters of Medicare-covered employment • Deductible ($1024 in 2008) • Coverage: Hospitalization Skilled Care rehabilitation service– 21 days plus 80 days with $124/day deductible May cover Home Health Services (co-insurance applies) Hospice Care

25. Public Financing - Medicare • Part B – Medical Insurance (like major medical insurance plan) • Funded by monthly fixed-rate premiums ($96.40/mo 2008) • Pays 80% of approved charges Doctor’s services Outpatient hospital services Ambulance transportation Diagnostic tests, lab, mammography Physical , Occupational, Speech Therapy outpatient or in rehab agency NOT COVERED: prescription drugs, routine physicals, dental, cosmetic, foot care, hearing aids, vision

26. Public Financing - Medicare • Part D – Prescription Drug • Voluntary participation • “Doughnut Hole” coverage • Monthly premium based on plan chosen

27. Diagnosis Related Groups (DRG) • A set fee is used , based on illness category, to determine hospital reimbursement • Medicare and insurance • Hospitals receive flat fee, regardless of length of stay • Hospital makes money if they provide service for less than DRG amount • Goal – care provided in most economical fashion possible • Prospective-Payment system

28. Public Financing - Medicaid • Medical assistance for low income and disabled • State establishes services and requirements, including eligibility

29. Health Care Financing – Managed Care HMO – Health Maintenance Organization • Prepaid fee paid to provider for comprehensive care of the enrollees • Encourage preventative medicine • Discourage excessive tests and treatments • Patient may not have option of choosing physician each time treatment is needed • Single point of entry

30. Health Care Financing – Managed Care Preferred Provider Organization (PPO) • Insurance companies contract with groups (physicians and hospitals) for discounted fees • Patient may see anyone in the network

31. Health Care Financing – Managed Care • Open Access – individuals may see specialists within network without a referral • Gatekeeper – usually primary physician – must give referral before patient can see specialist – goal is to keep costs down

32. Issues • US rankings by WHO • #1 – dignity, provider choice, confidentiality • #37 – performance (outcomes vs expenditures) • #54 – fairness in financing Hill, p. 317

33. Issues • Uninsured • Uncompensated care • Aging population • Cost of government health care programs • Cost of prescription drugs • Quality

34. Issues • Limited resources – how are they allocated, and to whom? • Private vs National Healthcare

35. Nurses’ Response to HCDS Issues • Cost containment • Quality Improvement • Health, prevention focus • NP’s providing care • Education

36. HCDS Issues in the Workplace • Use of UAPs • Nurse/Patient Ratios • Acuity levels • Mandatory Overtime • Unionization

37. Assignment • You are the self-employed head of household for a family of four. Your gross annual family income is $33, 280 (equivalent of $8/hr full time for 2 people). • Research the cost of a family health insurance policy with a $500 deductible. • What is the monthly and annual cost of this policy. What % of your annual income will be spent on health insurance?